Sorry, Medical Students, But You're Not Entitled To Your Dream Job

By Jack DePaolo — Mr. DePaolo is an M.D./Ph.D. candidate at Louisiana State University and a Student Director of the National Resident Matching Program.

The process of matching graduating medical school seniors with residency programs attempts to satisfy the desires of trainees and programs, with the goal of ultimately benefiting patients. In a recent piece, medical student Amy Ho listed several complaints with the current process of matching residency applicants with programs. In fact, she believes the National Resident Matching Program (NRMP) and the Main Residency Match ought to be done away with altogether. As a fellow physician-in-training and a member of the Board of Directors of the NRMP, I disagree with Ms. Ho’s arguments in numerous ways.

First, and for the sake of clarification, graduating medical school in no way entitles one to the residency program, specialty and/or geographic location of his/her choice, or to any kind of “dream job” as Ms. Ho argued in her piece. On the contrary, while graduating medical school is an accomplishment, it is merely a milestone on the path to becoming a competent, fully-licensed physician. Also, more desirable, competitive residency positions are just that – competitive. Though the Match systematically organizes competition among applicants for coveted slots, eliminating the Match would not erase the competition at all; rather, it would make the process much more chaotic.

In her column, Ms. Ho decried the Match because it leaves so many medical graduates without a place to continue training. However, there were 1.65 residency slots per US allopathic medical graduate in the 2014 Match. Two of the most prevalent reasons applicants do not match are that they apply only to extremely competitive residency programs and specialties for which they are not competitive, or they simply do not rank enough programs to adequately diversify and minimize the risk of not matching. Likewise, although there are certainly financial incentives to apply for competitive specialties, applicants must be honest in their self-assessment of which programs and specialties are realistic given one’s academic record. This kind of self-assessment is commonplace in careers other than medicine.

Ms. Ho also criticized the Match for contributing to the financial burden placed on graduating students. Traveling throughout the US and interviewing for programs is expensive, but such travel would be necessary even in the absence of the Match. It is completely unreasonable to think that without the Match one would simply arrange a single trip to Mass General Hospital for example, apply and interview for a position in internal medicine, and need not travel elsewhere. The only certain reduction in cost would be the elimination of the $60 NRMP fee that, when discussing the hundreds of thousands of dollars of debt incurred by medical students, is rather insignificant in exchange for the fairness and transparency the Match ensures. Furthermore, there would be no barrier to individual programs charging applicants fees that could dwarf the current cost of registering for the Match, much the same way individual medical schools charge applicants fees today.

Originally, the Match was the response of the academic medical community recognizing the intense pressure being placed on graduating medical seniors. Ms. Ho seemed to accept that the Match was created to protect individual applicants from abuses of power by program directors, but she dismissed the power differential that remains between programs and individual applicants in the residency selection process. Even today, with contracts in existence clearly spelling out the rules for interviewing applicants, some program directors push (and some exceed) the limits in the questions/requests they ask of applicants. Each year there are cases of rules violations by program directors subverting the system and attempting to ascertain during the interview process exactly where an applicant plans on ranking a given program. Although eliminating the Match might benefit the most qualified applicants, such unrestricted pressure from programs placed on average applicants would inevitably disadvantage them greatly by eliminating the option to thoughtfully consider and choose among programs.

Additionally, Ms. Ho concluded that residents are missing out on higher salaries by not being able to negotiate terms of contracts. It would be wonderful to imagine residents having the ability to use free-market tactics to negotiate contracts with individual programs, but the thought that such a process would happen is laughable. As medical graduates, it is important to remember that we are not yet fully-licensed, competent physicians able to demand fees for our services on an individual basis. Rather, we are learners who require the infrastructure of a teaching hospital, complete with senior residents, fellows, and attending physicians, to see patients and perform procedures. Indeed, as much as we are offering our unrefined services to residency programs, they are in turn offering their training services to us. Much like an attorney having not passed the bar examination, a medical degree without residency training is simply incomplete and is certainly not lucrative either historically or today.

Finally, Ms. Ho argued that the Match is bad for patients when doctors do not get their “dream job.” There is no proof of that assertion, and if physicians who do not match in their most preferred program mistreat their patients, it is time to rethink who we accept into medical school. What is certain is that a lack of geographically-distributed physicians with diverse specialties (including some of the less-lucrative, primary care specialties) is detrimental to the overall health of our society. Dream jobs are not entitlements to be collected with M.D. diplomas.

There are several ways we can contemplate improving the process of graduate medical education in the US, and we should seek to do so. However, the idea that jettisoning the Match would benefit US medical graduates is misguided. The NRMP does not require medical graduates to perform residency training; licensing boards authorized by state legislatures mandate that. The NRMP orchestrates the Match so that the process is as transparent and fair as possible. Furthermore, it facilitates the complex process of aligning the goals of young physicians with the needs of society, and in doing so allows training slots to be filled in a way that is mutually beneficial for physicians, residency programs, society, and our patients.

I am Forbes' Policy Editor, and president of a non-partisan think tank, the Foundation for Research on Equal Opportunity (FREOPP.org), which develops policy reform ideas to expand economic opportunity to those who least have it. I'm on Twitter at @Avik. My work has also...